What a great question! EMR/EHRs, workflow systems, BPM, and financial applications are converging and we (patients, physicians, solution developers) should all be glad they are finally doing so.

Process-aware technologies such as workflow management systems and business process management suites have matured and proven their worth in various industries. They will diffuse throughout healthcare. At the same time, traditional (that is, non-process-aware) electronic medical/health records (EMR/EHR) are coming under increased critical scrutiny. Many EHR implementations fail, estimates range from 30 to 70 percent. Government efforts to increase EHRs adoption by physicians paradoxically have had the opposite effect. A big part of the problem is that physicians realize that traditional EHR workflow is one-size-fits-all, and therefore does not fit them. In response, a growing number of EHR professionals are beginning to realize that physicians are not the problem; it is lack of usable and flexible EHR workflow.

EMR/EHR productivity, usability, and workflow issues are effectively blocking adoption of a technology, which if it were to be adopted, would greatly improve (1) our knowledge of what works and what doesn’t (clinical outcomes research), (2) coordination of care between clinicians and clinicians and between clinicians and patients (interoperability), (3) real-time monitoring of patient care (alerts, reminders, compliance with care plans), and (4) means to systematically improve medical care effectiveness, efficiency, and patient and physician satisfaction.

EMR/EHR productivity, usability, and workflow issues are inextricably intertwined, a Gordian knot of interdependencies. Process-aware technologies such as workflow engines, process definitions, and business process management techniques are promising ways to manage these interdependencies.

Non-process-aware EHRs are difficult to optimize in a business process management sense. Their workflows and processes are too highly constrained by design and implementation decisions made by traditional programmers using third generation computer languages. A physician should not have to rely on a C# or Java programmer to tweak his or her workflow. Lack of easily changeable workflow/process definitions at points of care, and points between, makes systematic improving clinical workflow difficult, slow, and expensive.

EMR/EHRs built on workflow management system/business process management suite foundations are the next logical evolutionary step of EHR technology. They are essentially a new class of clinical information systems, existing at the intersection between two great software industries: electronic medical/health record systems and process-aware workflow management systems/business process management systems. The hybrid EMR workflow systems that will result will be more usable and more systematically optimizable than traditional EMRs with respect to user and patient satisfaction, clinical performance, and hospital and medical practice financial viability.

That’s the vision, at least. The reality is that I am aware of one well-known EHR workflow management system/business process management suite on the hospital side and one such system on the ambulatory, medical office side. I am also aware of a number of document imaging/scanning workflow systems used by healthcare payers and in non-clinical hospital departments; however I don’t “track” them. Without structured syntax and semantics of patient-specific data, the following important activities will not be possible: clinical outcomes research, institution-to-institution coordination of care, real-time patient care activity monitoring, and the process mining that will be necessary to improve the these activities.

Fortunately, I am seeing an uptick in interest by healthcare organizations and health information technology vendors in process-ware/workflow management system/business process management approaches to problems that traditional EMRs have failed to solve. This interest is evinced in trade publication articles about the potential for BPM in healthcare, press releases about new initiatives to use a BPM system in a healthcare venue, blog posts and comments (see below), occasional job announcements, and excellent questions such as yours.

For example, the following is a randomly picked blog comment (not my blog or comment, see http://j.mp/5R9N3s, written by someone familiar WfM/BPM but directed toward the physician blog author):

“Most existing EMR systems are a combination of data collection and storage (the facts) and the workflows associated with these facts (e.g. the follow-ups, ticklers. Etc.) The facts can be standardized but the workflows vary from practice to practice and physician to physician….Most existing EMRs handle workflow as if every physician/practice were identical…There is a whole separate class of software products with names like workflow management or business process management which is focused on how facts flow between people and what happens when flows are interrupted…Once you’ve seen a general workflow system in action you never want to go back.”

You also mentioned integration of fiscal applications into the EMR/EHR BPM mix. As great a picture as I have painted, the picture that results when you add financial data is even more extraordinary. I used to work in a hospital MIS department (wow! when I think about that potential!). However for the last decade I’ve worked in the primary care industry, specifically in pediatric and primary care. So in my following comments about combining clinical cost and clinical workflow data I will stick to what I know. However, I think you can extrapolate to other specialties and institutional venues.

One of the great promises of EHR workflow management systems in general, and primary care EMR workflow systems in particular, is the pairing of activity-based costs with process definitions. Since each step in a patient encounter process definition is time stamped as to when it is available to be accomplished, when it starts to be accomplished, and when it is actually accomplished and who (cost per minute) and where (rent per minute) is the resource used during each task, the total cost of each patient encounter can be calculated. With the revenue per pediatric encounter that is available from the practice management system (a fiscal application), the profit per each encounter can be calculated.

By comparing encounter profitability across similar medical practices, specific reasons for decreased profitability can be located: (1) a step is more expensive per minute than it should be (that is, it is accomplished by less expensive resources at other medical practices), (2) a step takes longer to accomplish than it should (compared to other practices), and (3) a step is executed more frequently than it should (compared to other practices). The win-win-win analytic result is to find those too expensive and too long steps being executed too often and change the workflow to increase encounter profitability.

That’s just one example of the power of combining EHRs, BPM, and cost data.

So, to answer your question: “In the healthcare environment, are their institutions using BPM software platforms in conjunction with ERP (fiscal) and EHR (medical platforms)?”:

There are a couple of mature existence proofs that EMR/EHR workflow systems/BPM platforms work well and have excellent potential. A metaphorical light bulb is turning on over the collective heads of the healthcare IT industry. And there are excellent questions like yours. Thank you for asking it!

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Robot-In-My-Pocket

Charles Webster, MD, MSIE, MSIS

Bio: HIMSS14 & HIMSS15 Social Media Ambassador! If you've got a healthcare workflow story, I want to tell it, blog it, tweet it, interview you, etc.
Chuck Webster, MD, MSIE, MSIS has degrees in Accountancy, Industrial Engineering, Intelligent Systems, and Medicine (from the University of Chicago). He's the ex-CMIO for a three-time HIMSS Davies Award-winning pediatric EHR. Dr. Webster currently services as CMIMO (Chief Medical Informatics Marketing Officer) for workflow technology in healthcare. Chuck also created Mr. RIMP (@MrRIMP) (Robot-In-My-Pocket) a Bluetooth-controlled wearable robot for pediatricians and child life specialists to entertain children. Dr. Webster designed the first undergraduate program in medical informatics, was a software architect in a hospital MIS department, and is a judge for the annual Workflow Management Coalition Awards for Excellence in BPM and Workflow and Awards for Case Management. Chuck is a ceaseless evangelist for process-aware technologies in healthcare, including workflow management systems, Business Process Management, and dynamic and adaptive case management. Dr. Webster tweets from @wareFLO, @EncounterPRO, and @MrRIMP (though there is some debate about the last one). He maintains almost a half-a-million words and graphics on numerous websites, including EHR Workflow Management Systems (http://chuckwebster.com), Healthcare Business Process Management (http://HCBPM.com) and the People and Organizations improving Healthcare with Health Information Technology (http://EHRworkflow.com). Please join with Chuck to spread the message: Viva la workflow!